Counting hospital activity: spells or episodes?

This study looked at inpatient spells for myocardial infarction (ICD-10 I21 and I22) between 1996-7 and 2002-3 to examine the impact of using different criteria for determining numbers of myocardial infarctions over time

For all seven years, there were 538,560 inpatient spells that had a primary diagnosis of myocardial infarction in the first episode of care, compared with 754,589 episodes with the same primary diagnosis

The difference between spells and episodes increased each year, from 27% in 1996-7 to 53% in 2002-3

In 2002-3, 36% of spells with a primary diagnosis of myocardial  infarction in the first episode seemed to have a duplicate diagnosis in subsequent episodes. This varied by trust from 0% to 100%.

There are considerably more episodes with a primary diagnosis of myocardial infarction than there are spells. In both spells and episodes, the increase in 2002-3 may reflect recent changes in diagnostic criteria for myocardial infarction. The interpretation of a finished consultant episode does not seem to be consistent across different providers. Some patients with an initial diagnosis of myocardial infarction may go on to have a subsequent infarction within a spell, although there is no reason why that should be included as an extra episode.

This may result from a stay in an emergency ward in addition to an episode of care on a general medical ward. Measuring hospital activity by episode could result in overestimates of up to 50% for myocardial infarction. In 2.9% of spells, vague symptoms and signs were noted in the primary diagnosis of the first episode with myocardial infarction in the subsequent episode. Overestimates carry obvious implications for estimating the incidence of disease and assessing healthcare outcomes

Source: Web

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Medically unexplained symptoms

At least 20-30% of primary care patients have medically unexplained symptoms. Current evidence indicates that medical care of medically unexplained symptoms should include improvements in three interrelated elements—diagnosis, specific treatment strategies, and communication.

The concept of medically unexplained symptoms includes a spectrum of disorders ranging from mild transitory illness to chronic disorders with severe disability. Many of the affected patients do not receive a correct diagnosis and undergo numerous fruitless investigations and attempts at treatment. The narrow focus on the somatic aspects of a complex problem may reinforce their concerns about having a physical disease, make them less satisfied with the healthcare system, contribute to the development of chronic disablement, and cause healthcare costs to become excessive. At the same time doctors become frustrated when dealing with medically unexplained symptoms.

Substantial evidence shows that medically unexplained symptoms can be treated effectively by specialists using, for example, cognitive behaviour therapy However, such specialist treatment is seldom available and even at best would be an option for only a minority of the patients encountered in general practice.

We also need programmes targeting the management of medically unexplained symptoms in the primary care setting. A systematic review of specific somatisation treatments in general practice described 10 randomised trials, but most of the treatments reviewed required the participation of specially trained therapists.

Recent qualitative research into aspects of the communication between doctors and patients has shown that doctors' usual ways of communicating with patients who have medically unexplained symptoms may need  adjustment. Patients seem to be prepared for simultaneous biological and psychosocial approaches to evaluation of symptoms. The methods currently used by general practitioners to reassure patients that their symptoms are part of normality are insufficient. If reassurance does not address the patients' specific concerns it may exacerbate their presentation of somatic symptoms

. These findings are in line with previous observations that doctors' explanations are often at odds with the patients' own thinking and result in conflict, a feeling of rejection, and undermined confidence.

In conclusion, we should offer the same professional management and quality of care to the many patients with medically unexplained symptoms as we offer to patients with explicable symptoms. Today this is not the case, and we need to bring existing evidence into medical education and to renew our management of patients with medically unexplained symptoms in general practice. In this process we must also be ready to adjust paradigms about good communication based on new evidence.

This process should be driven by comprehensive research into patients with medically unexplained symptoms and by health services research exploring the best possible implementation of appropriate management strategies.

Source: web

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Concealment of drugs in food and beverages in nursing homes

This study was set up to examine the practice of concealing drugs in patients' foodstuff in nursing homes. It was a cross sectional study with data collected by structured interview in all five health regions in Norway.

They studied the professional carers of 1362 patients in 160 regular nursing home units and 564 patients in 90 special care units for people with dementia.

They were interested in the frequency of concealment of drugs; who decided to conceal the drugs, how this practice was documented in the patients' records; and what types of drugs were given this way.

Overall 11% of the patients in regular nursing home units and 17% of the patients in special care units for people with dementia received drugs mixed in their food or beverages at least once during seven days. In 95% of cases, drugs were routinely mixed in the food or beverages.

The practice was documented in patients' records in 40% of cases. The covert administration of drugs was more often documented when the physician took the decision to hide the drugs in the patient's foodstuff.  Patients who got drugs covertly more often received antiepileptics, antipsychotics, and anxiolytics compared with patients who were given their drugs openly.

They conclude that the covert administration of drugs is common in Norwegian nursing homes. Routines for such practice are arbitrary, and the practice is poorly documented in the patients' records.

Source: web

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